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The majority of doctors combined the new bacteriological findings with the old idea of hereditary susceptibility. As the infective nature of TB gained greater acceptance, attempts by MOsH to institute specific preventive measures yielded success by the end of the century.223 Tubercles, small nodules in the lungs filled with caseous material, had been identified in the seventeenth century, but it took another 100 years for them to be recognised as pathognomonic of pulmonary TB, known at the time as phthisis by doctors and consumption by the general public. These three terms are similar and will be used to mean the same disease, bearing in mind the difficulties over accurate diagnosis in the nineteenth century.224 TB is spread by airborne droplets from the sputum of infected humans or in milk from infected cattle. It can affect many organs throughout the body other than the lungs, most commonly the skin, causing lupus vulgaris, and the lymph nodes, known as scrofula. Only about one in ten of those infected develop the pulmonary form, which results in cough, low-grade fever, haemoptysis, night sweats and general wasting, giving it the name of the White Death.225 It kills 80% of sufferers within five to 15 years.226 Treatment in the early nineteenth century was palliative, focussing on the most distressing symptoms of cough, night sweats and diarrhoea. Later, but prior to Koch’s discovery of the tubercle bacillus, therapy strove to concentrate the body’s ability to overcome the disease through rest, to improve nutrition by a suitable diet and to Worboys, Spreading Germs, p.194.

Koch initially labelled the bacillus he identified in the tubercles as tubercle bacillus, but it is now known as Mycobacterium tuberculosis. Infection in humans can also occur from the bacillus that infects cows, namely Mycobacterium bovis.

Dobson, p.64.

Dormandy, p.22.

strengthen the lungs by moving to purer atmospheric conditions. Cod liver oil and bathing were also popular remedies. In the 1880s, the inhalation of antiseptics, such as creosote, came into vogue. In 1890, Koch introduced tuberculin, an extract from culture plates of the bacillus, as a specific treatment, but it was soon dismissed as ineffective.227 Nevertheless, Birmingham guardians acceded to the visiting physician’s request to order ‘50 marks worth’ of Dr Koch’s lymph from Berlin.228 Climatic treatment became the gold standard, aiming to place the patient in the environment most likely to limit progression of the disease. It was often combined with exercise to promote full ventilation of the lungs.229 In the 1880s, this developed into the ‘open-air treatment’, in which the location became less important than spending as much time outdoors as possible, as outdoor air would contain less bacteria than indoor.230 The essential factors in open-air treatment were described by a sanatorium physician in 1909 as ‘air, rest, feeding and supervision’, plus ‘time’.231 Open-air treatment, which was developed in Germany in the 1860s and introduced into Britain in the 1890s, became an established part of the therapeutic regimen in sanatoria.232 Although isolation of infected individuals was a significant part of their role, they were promoted as providing a cure, through a therapeutic regime of diet, exercise, strict monitoring of temperature and weight, as well as exposure to fresh air, either in huts in the sanatorium grounds or in wards with the windows wide open.233 Because of the stress on the curative role of sanatoria, admissions were selected to prevent admission of more advanced cases, who frequently ended their lives in poor Worboys, Spreading Germs, p.225.

BCL, WIMC, GP/B/2/3/3/2, 28 November 1890.

Worboys, Spreading Germs, p.218.

M. Worboys, ‘The Sanatorium Treatment for Consumption in Britain, 1890-1914’, in J. V.

Pickstone (ed.), Medical Innovations in Historical Perspective, New York, 1991, pp.50, 52.

F. W. Burton-Fanning, The Open-air Treatment of Pulmonary Tuberculosis, London, 1909, p.83.

Worboys, ‘The Sanatorium Treatment’, p.47.

Ibid., p.52; Bynum, Spitting Blood, p.134; F. Condrau, ‘Beyond the Total Institution: Towards a Reinterpretation of the Tuberculosis Sanatorium’ in F. Condrau and M. Worboys (eds), Tuberculosis Then and Now, Montreal, 2010, pp.80-81.

law infirmaries.234 Consumptives were also excluded from admission to voluntary hospitals for similar reasons. Specialised facilities were very inadequate, with only 14 sanatoria and 1,000 beds in Britain by 1910.235 As a result, many poor law infirmaries included sanatorium wards; 12 in London provided open-air treatment and a sanatorium ward was in place in Sheffield around 1904. Purpose-built poor law sanatoria were established in Liverpool in 1902 and Bradford in 1903.236 Reading Union did not establish dedicated facilities until 1912, providing one ward with four beds for women and one for men with eight beds.237 In the early 1850s, the number of patients suffering from consumption in Birmingham workhouse was usually in single figures (Appendix B).238 When Edward Smith visited on 12 November 1866, there was a designated ward for consumptive cases, containing 19 beds out of a total of 630 in the infirmary.239 In a national report four years later, there were 26 patients in the infirmary categorised under the ‘Phthisis and Tuberculosis’ heading, constituting 3.7% of patients under the care of the MO, 1% greater than the national average. However, there were no patients with phthisis or consumption in Wolverhampton workhouse in that year.240 Around 80 patients with consumption were present in Birmingham when the guardians decided to provide a dedicated ward for open-air treatment, prompted by moves nationally to take measures to manage TB.241 Dr Short, one of the visiting physicians, cautioned against having all phthisis patients together because of cross-infection between patients.

F. B. Smith, The Retreat of Tuberculosis, London, 1998, pp.238-39.

Cronjé, p.82; Worboys, ‘Sanatorium Treatment’, p.48.

Worboys, ‘Sanatorium Treatment’, pp.52, 55-56, 216.

Railton and Barr, p.143.

TNA, MH12/13297-99, 13300.

BPP, 1867-68 (4), p.46.

BPP, 1870 (468-I), pp.11, 143, 147.

BCL, WIMC, GP/B/2/4/4/3, 29 July 1901; BBG, GP/B/2/1/71, 3 September 1902.

Many of the patients were, he considered, in Class I in the last stages of the disease.

Those in Class II also suffered from bronchitis and because of this were not suitable for open-air treatment. He estimated that there were no more than six cases of those in the early stages (Class III) who had been in the infirmary in the year and only they would benefit. However, he was not in favour of open-air treatment being carried out in the infirmary grounds because of the cold and windy atmosphere to which the patients would be exposed and he cautioned that treatment for less than six months would be useless. Dr Kauffman agreed with him, except that he thought it worthwhile trying it at the infirmary and that Class II would benefit. The third visiting physician concurred with Dr Kauffman, but added that patients would need to agree to undergo treatment for a minimum period of six months. The committee agreed to go ahead with special provision for a few patients, but also to transfer some to a sanatorium.

Three sufferers who showed willingness to stay for at least three months were transferred to the Midland Open-Air Sanatorium at Belbroughton at a cost of £1.11.6 each per week, as there was no sanatorium provision in Birmingham at that time.242 The phthisis hospital in Birmingham infirmary, which cost £444, was operational by the beginning of July 1903, all six beds being occupied by men, each having a separate room.243 From that date to 26 September the next year, there had been 15 admissions and 10 discharges; details of the five remaining patients are contained in Table 3.6. The ages of nine of those discharged ranged from 19 to 58 years, with a mean of 41. Four were discharged at their own request, three as they had not improved and three described as ‘unfit’, presumably meaning not suitable for treatment.244 In the following six months, 18 men were admitted, 14 discharged, BCL, WIMC, GP/B/2/4/4/4, 17 February, 15 December 1902; IHSC, GP/B/2/4/5/3, 23 December 1902; Dormandy, p.166.

Ibid., 31 August, 6 October 1903.

BCL, IHSC, GP/B/2/4/5/3, 26 September 1904.

leaving four remaining in the ward. Dr Kauffman reported that patients with relatively advanced disease did badly, while those with bronchitis and suspected phthisis were apparently cured. Overall, ‘hopeful’ cases showed marked retardation of disease after three months, with the greatest improvement in the early period of stay.245 The number of admissions of patients with phthisis decreased from 297 in 1904 to 177 in 1905 and 156 in 1906.246 On 21 May 1906, there were 85 men and 10 women in the infirmary at different stages of the illness. Two women and 14 men were in the early stage, three women and 33 men in the active middle stage and 4 women and 15 men in the active advanced stage. One woman and 23 men had chronic disease and Table 3.6: Phthisis Patients in the ‘Phthisis Hospital’ in Birmingham Workhouse on 16 September 1904

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the MO recommended separate accommodation for them to prevent spread of infection.247 The reduction in admissions resulted in no patients being transferred to Ibid., 6 March 1905.

BCL, WIMC, GP/B/2/4/4/5, 25 February 1907.

Ibid., GP/B/2/4/4/4, 21 May 1906.

the phthisis block in the three months to January 1908. Two patients in the block had developed renal inflammation; one had died and the other had been transferred to a ward in the infirmary.248 As a result, the guardians debated the benefit of continuing with the arrangement. Dr Jordan, who had taken over the care of patients in the block, advanced two reasons why it had not been as successful as expected. First, the quality of the atmosphere was too impure because of many surrounding factories, which also restricted the amount of sunshine.249 In saying this, he was attributing the therapeutic benefit to the inspired air, a belief supported by Condrau, who asserts that the prime ingredient of institutional therapy was ‘fresh air’. However, Worboys disagrees, claiming that it was not pure air that was the therapeutic agent, but the regime in the sanatoria.250 This accords with Dr Jordan’s second reason for failure of the phthisis block, namely the lack of supervision of patients due to its distance from the main building. He added that, on one occasion, one of the medical staff paid a surprise visit to the block and found that the inmates had closed all the windows and doors, which, he claimed, would delay their progress by two months.251 The inmates’ actions support Condrau’s assertions that patients are not merely objects of institutional therapy and that an institution exists independently of its inmates.252 Dr Jordan suspected that TB sufferers would not present for admission to the infirmary at an early enough stage of the disease to be suitable for open-air therapy as they would prefer to continue working as long as possible and he concluded that patients would gain more benefit in dedicated wards within the infirmary. The decision was taken to Ibid., GP/B/2/4/4/5, 27 January 1908.

Ibid., 9 March 1908.

Condrau, pp.80-81; Worboys, ‘Sanatorium Treatment’, p.52.

BCL, WIMC, GP/B/2/4/4/5, 9 March 1908.

Condrau, p.80.

close the block accordingly, no doubt aided by the fact that the efficacy of sanatorium treatment was beginning to be questioned at that time.253 The WMO at Wolverhampton also practised open-air treatment. Early in the twentieth century, the guardians requested the architect to determine how the buildings proposed for the new workhouse could be adapted to provide ‘outdoor treatment of phthisical cases’.254 However, no dedicated facilities are included in the plan of the hospital dated 1902.255 After the new workhouse had been operational for one year, the MO suggested conversion of a window into a doorway in the surgical ward, which contained patients suffering from TB of bones in the leg and spine. This would prevent them from being carried out through a corridor and airing court and give direct access to the outside of the ward. He stressed that open-air treatment was necessary for these patients.256 It took the guardians almost two years to seek the approval by the LGB for the alteration, and a further year for the LGB inspector to visit to give his approval.257 Three years later, the guardians agreed to widen a door so that patients could be moved out of the ward in their beds.258 In the meantime, the guardians approved the purchase of six coats to enable phthisical men to get out in the open-air as much as possible.259 They were also concerned regarding phthisical patients ‘expectorating on the floors’ because of the danger to other patients and threatened any doing so with prosecution for disobeying rules.260 Birmingham BCL, WIMC, GP/B/2/4/4/5, 9 March 1908.

WALS, New Workhouse Committee, PU/WOL/S/1, 27 November 1901.

WALS, Block Plan, Wolverhampton Union Workhouse, DX/120/10/10, 1902.

WALS, HC, PU/WOL/E/2, 15 December 1904.

Ibid., 20 September 1906, 31 October 1907; PU/WOL/E/3, 9 June 1910.

WALS, HC, PU/WOL/E/3, 9 June 1910.

WALS, HC, PU/WOL/E/1, 11 February 1904.

WALS, Special Committees, PU/WOL/P/1, 25 January 1906.

guardians also considered the provision of ‘receptacles for the spittle of phthisis patients’ and the best way of disposing of it safely.261 In the year ending Michaelmas 1908, there had been 346 admissions due to TB into

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